Victims of Hubris

I had a case review ready to post, but recent events in Colorado have inspired me to take a different tack for this month s column. I ll save the completed case for another time, another month.

I live in Colorado Springs, a conclave of large religion-based organizations. So, perhaps it might seem natural that I m going to take the liberty to preach from the pulpit, so to speak. But my subject isn t God.

For readers who might be expecting the routine, I apologize and ask your indulgence. If you can t stand a hint of proselytizing, you can, of course, vote to move on with a simple click of your mouse. But I hope that you won t.

Two weeks ago, I received a complaint from the father of a 30-year-old female patient who was transported in February by our ambulance service. The father did not feel the bill was justified. He stated that he was a former paramedic and, as such, was generally knowledgeable about prehospital care.

I learned the father was irate because his daughter was not transported to the hospital using lights and siren (Code 3). As a result of this violation of the standard of care, he was refusing to pay the bill. (It s not clear why the father was responsible for the bill.)

The patient was employed at a local store and, at about 10 a.m., began to suffer symptoms suggestive of a stroke. She became lightheaded and felt that she might pass out. Shortly after, she noted weakness in her left upper and lower extremities.

9-1-1 was contacted within 10 to 15 minutes of symptom onset, followed very shortly by the arrival of our fire department and ambulance company. Medical history obtained by the crews revealed difficulties with complex migraine headaches. There were no other pertinent problems.

A physical exam demonstrated slight to moderate weakness in the left upper and lower extremities. No other abnormalities were observed, and vital signs were normal as well.

In the meantime, the father arrived on scene. The ambulance then transported the patient to the facility of her choice without lights and siren (Code 2). The woman remained stable during the 20-minute trip over a 10-mile route.

Once at the hospital, the patient was evaluated by the emergency physician and deemed to be a candidate for tissue plasminogen activator (TPA) treatment. The clot-busting drug was administered, and the woman reportedly regained complete function of her extremities. Further hospitalization was uneventful.

In his letter, the father made the following allegations:

The patient had only 45 minutes from symptom onset to get to the hospital in order to be a candidate for TPA. (In fact, the time is three hours or 180 minutes.)

He could have and should have driven the patient to the hospital himself in less time than the ambulance did.

Code 2 transport reflected a lack of appreciation, if not complete understanding, of the grave emergency represented by the daughter s complaints.

Failure to drive with lights and siren breached the standard of care and subjected the crew, and our ambulance company, to the threat of medical/legal action.

For all of these reasons, at the very least, the ambulance company should forgive the $800 bill submitted to the patient.

The irony of his letter is amplified by the fact that it came to me the very week I learned of our local EMS tragedies. For those who may not be aware, three people were killed in two separate Colorado ambulance crashes in May.

One of these incidents occurred when an ambulance was responding Code 3 to a fire standby. The vehicle collided in an intersection with a car being driven by a 16-year-old girl. She had her driver s license for exactly one month when she died.

The second crash happened on an interstate highway. A high-risk obstetrics crew was accompanying a patient en route from Nebraska to Denver. The patient s sister-in-law was also riding along in the back of the modular ambulance. The vehicle collided with a tractor-trailer and lost control. The nurse and sister-in-law were killed. A paramedic who was belted in at the head of the patient suffered only minor injuries, as did the crew riding in the front of the ambulance.

So while I was trying to compose a response to the angry father explaining why it was, in fact, appropriate to transport his daughter Code 2, I was thinking about this teenager (one year older than my own daughter) and the other two victims who were now lying in refrigerated drawers at the morgue.

I am by no means the first in our profession to raise the safety alarm; many have done so before this. However, a large portion of our industry has not yet chosen to venture here, and it s time that we do something. I mean really do something, rather than just give lip service.

Late last year, the Transportation Committee that I chair (a subcommittee of Colorado s State Emergency Trauma Advisory Council SEMTAC) was identifying its objectives for 2006, and we decided to focus on ambulance safety in our state. We asked Nadine Levick, MD, the foremost researcher in ambulance safety, to give a presentation at our January 2006 SEMTAC meeting.

Most of us had not seen Dr. Levick s lecture, so her talk was an eye-opener for nearly all in the room. Additionally, SEMTAC received information on two Safety Concept Ambulance models built for American Medical Response (AMR).

Thus, in a small way, our state had already been thinking about the importance of safety. But the two recent fatal crashes have brought the issue to the front burner. I hope to convince you to bring the issue to the front burner in your state as well.

What can we do? Detailed answers are beyond the scope of my expertise and the space available for this article. But we obviously need to focus on short- and long-term solutions.

One short-term fix: We must immediately re-examine and curtail Code 3 responses and transports. We must acknowledge that the rate of crashes involving emergency vehicles using lights and siren is substantially greater than the rate of accidents with similar vehicles not using lights and siren. A large body of research supports this statement. Therefore, we must find ways to decrease the use of this modality, despite the complaints we may get from individuals who are blind to the risks of running hot.

In the culture of emergency medicine, some think it s cool or macho and an adrenaline rush to crank up the lights and siren. Maybe some providers even came into our profession looking forward to using these toys. Certainly, TV shows and other media contribute to this fascination.

Think about it. Do you know anyone who seeks reasons to run Code 3, willing to put themselves, their fellow crew members and the public at risk for their excitement? How arrogant. How prideful.

Hubris is defined as the excessive pride, arrogance and ambition that usually leads to the downfall of a hero. I'm not claiming to definitively know the circumstances of every police, fire and EMS situation involving the use of Code 3, but I think recent experience demonstrates plenty of instances when we ve witnessed the downfall of some heroes.

And when that happens, we create multiple victims out of ourselves, our families, our patients, and innocent bystanders and their families. The trickle-down effect from this indulgence is enormous.

I realize that inappropriate lights-and-siren use is not solely the fault of EMS providers. Complicating the whole picture are lousy protocols that may encourage Code 3 transports or at least fail to be clear about the option of Code 2. Many agencies offer little or no training on how, or when, to use lights-and-siren responses. Additionally, we all know that it s pretty damn common to have the harried hospital physician tell us to go hot with the patient, even though they have zero understanding of the risks to EMS, their patient and the public.

In my opinion, EMS should be traveling only 10 miles per hour over the posted speed limit when Code 3. The fact is that in an urban setting, lights-and-siren status saves maybe two to five minutes in total transport time. Rural time savings are equally minimal. We know that for more than 95 percent of our patients, that amount of time difference has absolutely no bearing on their clinical outcomes.

So we need to be smarter. We need better protocols, and we need to crack down on the bozos in our profession who refuse to get it. We need to dispatch using such algorithms as Medical Priority Dispatch to help us get to patients using the appropriate status. Then we need to actually follow the dispatch criteria when it s given to us.

My view is that the only times we need to be driving hot to a hospital are when the patient has:

an unstable, unsecured airway (and that doesn t mean every patient should be intubated, because they shouldn t);

significant hemodynamic instability or

potentially significant major medical illness or injury and an ambulance gridlocked in traffic.

We should avoid Code 3 status whenever possible. If we must use it, such as in a heavy traffic situation, it should be only to get free of that traffic. We should then return to Code 2.

Think about the importance of ambulance safety. It s our responsibility. Speaking to you from a city of religion, I m saying this should be our religion. We have only touched on one solution; there are many more short-term and long-term fixes that must be implemented.

Another thing we can all do is advocate. Advocate for the concept in your agency, your hospital, your city, your region and your state. Advocate for better training on the use of Code 3. Advocate for clearer protocols. Ask Dr. Levick to come to your area and speak. Experience the enlightenment that our group did in January. Listen to what she has to say and use her ideas to begin reducing your risks.

I had all of these thoughts in mind as I answered the father s letter. I informed him of the recent death of the 16-year-old girl who crashed into an ambulance, implying that this kid could have been his daughter. Would he prefer a Code 2 transport, or would he rather open a drawer at the coroner s office?

I m off my soapbox ... at least for now. Thanks for reading. And for being safe.